Provider Demographics
NPI:1346695038
Name:MITCHELL, MATTHEW (PHARMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5269 LOKI LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-7245
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:525 W ACACIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95203-2405
Practice Address - Country:US
Practice Address - Phone:209-944-5550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-29
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65544183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist